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General NPI Number Information
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NPI Number | 1679914469
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Entity Type | Individual
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Provider Name | JASON SHUPE D.O.
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Gender | Male
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Dates
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Enumeration Date | 07/10/2013
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 554 E FOOTHILL BLVD STE 120
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City | SAN DIMAS
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State | CA
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Zip | 91773-1222
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Country | US
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Telephone | 909-248-3437
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Fax | 844-380-6565
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Provider Business Mailing Address
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Address Line | 554 E FOOTHILL BLVD STE 120
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City | SAN DIMAS
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State | CA
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Zip | 91773-1222
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Country | US
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Telephone | 909-248-3437
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Fax | 844-380-6565
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20A13620
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 204D00000X
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Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
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License Number | 20A13620
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License Number State | CA
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